Osteoporosis Prevention in Inhaled Cortico-steroid Users Principle Investigators: Hoan Linh Banh, Pharm.D Andrew Cave, MBChB MClSc Valerie Chan, BScPharm ACFP:ASA Banff Feb27th 2014
Osteoporosis Prevention in Inhaled Cortico-steroid Users
Principle Investigators: Hoan Linh Banh, Pharm.D
Andrew Cave, MBChB MClSc
Valerie Chan, BScPharm
ACFP:ASA Banff Feb27th 2014
Conflicts of InterestDr Banh and Ms Chan have no
conflicts to declareDr Cave has received research
support from GSK, Astra-Zeneca, Novartis. Merck Canada, Grifols, Boeringer-Ingelheim but has no conflict related to this study
IntroductionInhaled corticosteroids (ICS):
◦standard maintenance therapy in controlling symptoms in asthma patients
◦and add on in moderate to severe chronic obstructive pulmonary disease (COPD)
Risk of osteoporosis with systemic corticosteroid use is well known but there is low awareness of risk with ICS
GINA Guidelines
Patients on (1) High doses ICS (defined as >2 mg beclomethason/day) OR (2) Oral glucocorticosteroids (any dose)
are considered at risk of developing osteoporosis and fractures.
Osteoporosis PreventionCalcium supplementation
◦Age 19-50: 1000 mg/day◦Age >50: 1200 mg/day
Vitamin D supplementation◦Age <50: 400 IU/day ◦Age >50: 800-2000 IU/day
Lifestyle Modifications◦Smoking Cessation◦Exercise◦Limit alcohol intake
ObjectivesPrimary: To investigate the extent of
osteoporosis prevention or treatment received by patients with asthma and COPD treated with ICS.
Secondary: To assess the number of patients, regardless of ICS dose, who met the requirements for an initial BMD scan, received the BMD and received appropriate follow up when indicated.
Methodology
Inclusion:◦Age ≥19 years◦ICS use ≥ 3 months in the past 12
months◦Willing to answer a questionnaire
Exclusion:◦Difficulty speaking English or
cognitively impaired
Results
- N = 255- Overall mean age = 60 years (SD = 17.4 years)- 66% Female – mean age 61 (SD = 17.1 years)- 34% Male – mean age 57 (SD = 17.7 years)
Results
> or = 65 years old < 65 years old0
10
20
30
40
50
60
70
80
90
100
Number of patients who received appropriate or pending BMD follow up vs. inappropriate BMD follow up
InappropriateAppropriate or pending
Num
ber
of p
atien
ts
Results SummarySubjects are more than twice as likely to
take appropriate vitamin D than calciumTaking apprpriate Vitamin D and Calcium
◦Low ICS users = 19%◦Medium ICS users = 21%◦High ICS users = 8%
Having appropriate osteoporosis prophylaxis or being treated for OP◦Low ICS users = 28%◦Medium ICS users = 30%◦High ICS users = 26%
Results Summary 2
29% of subjects(73/255) were found to be sufficiently supplemented or treated, regardless of dose potency
Either by adequate intake of both calcium and
vitamin D (45 patients) treated for osteoporosis (28 patients)
Discussion
◦High dose ICS users: (at highest risk)
62% ≥ 65 years old (age increases OP risk)
Had lowest appropriate intake of calcium at 13% (7/53)
? Pill size issue, constipation in older age
DiscussionStudy Limitations and Difficulties
◦Health Information Act Data may not represent all of Alberta
◦Restrictions imposed by pharmacy authority
◦Pharmacy settings with a low rate of returning patients
◦Subjective reporting Some subjects could not recall exact year
that they received follow up of BMD Dietary intake of vitamin D and calcium
hard to assess
Conclusion< 29% of patients are achieving
appropriate osteoporosis prophylaxis or treatment regardless of ICS dose
◦high dose ICS users (highest need of osteoporosis prevention) have lowest prevention/treatment rate (26%)
For patients who qualified for an initial BMD test, 61% received it.
AcknowledgementsCostco #544 – Sherwood Park, Alberta Shoppers Drug Mart #302 – Edmonton, AlbertaShoppers Drug Mart #312 – Edmonton, AlbertaShoppers Drug Mart #346 – Edmonton, AlbertaShoppers Drug Mart #386 – Edmonton, AlbertaShoppers Drug Mart #2301 – Edmonton, AlbertaLondon Drugs #22 – Edmonton, AlbertaSafeway Capilano – Edmonton, AlbertaSprucewood Pharmacy – Lloydminster, AlbertaWalmart #3118 – Edmonton, AlbertaWalmart #1570 – Camrose, AlbertaWalmart #7236 – Edmonton, Alberta